Control of tuberculosis may be defined as
a deliberate interference in the relationship between man and bacillus
that changes favourably the epidemiological trend. Compared with
the other factors at play on this relationship, the weapons available
for a control programme are narrow in their range and must be used
with great foresight if they are to benefit the country. Under Indian
conditions, with tuberculosis ubiquitous in its occurrence, with
no striking focality of infection and disease that would justify
selective restricted efforts, control measures must necessarily
cover the whole community and the programme must be maintained for
a long time. Control will be a slow process, demanding continued
investment of men and supplies, persistent and careful organisation.
There is no short cut.
The assessment of programme (performance)
requires similar approach. Evaluation (impact) must concern
itself initially with examining the operational and technical performance,
enquiring in detail how the immediate achievement has compared with
the forecast, as changes in prevalence are expensive to detect and
may not be due to control measures applied. In general, supervision
asks if a rule is obeyed: assessment enquires whether it
has really been obeyed, whether it can and should be obeyed and
whether there might be a better rule. For e.g. evaluation of BCG
campaign encompasses the whole series of activities undertaken and
not only confined to occasional surveys of post-vaccination allergy.
It is important for curative work also. Pilot evaluation report
of Anantapur programme after one year in 1962 is given as an example
of simple assessment. A great majority of patients diagnosed at
district centre came from outside, while at peripheral hospitals
90% came from the same taluk. Treatment completion were 38% to 40%
among patients belonging to the same town and very low among those
living outside. This gives importance of Case-finding in peripheral
centres. Referral also played very little part. The accuracy of
diagnosis, proportion of cases diagnosed, number completed treatment
and rendered negative, are included in the assessment. Besides these,
cost of the programme and expansion of the programme to the
whole district, accuracy of the case index, operational achievements
at individual centre/district, prevalence of initial drug resistance
among clinic patients, should also be considered. Even such an elementary
evaluation demands careful organization and clear procedures: staff
must be allotted and trained for the purpose and equipment
must be provided. The assessment must be objective and independent:
it seems appropriate that the procedures would be undertaken, in
each state, by staff from the State Tuberculosis Centre, Regional
Offices under the Union Government could also be involved. The responsible
centres must have portable, hand operated punching equipment and
facilities for sputum culture. If tuberculosis in India is to be
controlled by human intervention and health to be effectively promoted,
independent assessment of programmes, feeding back into research
so that problems will be solved and the solutions timely applied,
is absolutely essential. As yet, both methodology and the organisation
needed are embryonic and demand therefore particular attention and
priority. Administrators and scientists alike face, in nurturing
evaluation, an unusually difficult and promising challenge. Recognising
and accepting a challenge is in itself an important development.
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